Group Health Cooperative of South Central Wisconsin
http:// www. ghc-hmo. com
A Health
Maintenance Organization
Serving: South Central Wisconsin
Enrollment codes for this Plan:
WJ1 Self Only
WJ2 Self and Family
RI 73-061
For changes in benefits
see page 8.
2002
Serving: South Central Wisconsin
Enrollment in this
Plan is limited. You must live or work in our
Geographic service area to
enroll. See page 7 for requirements.
Special notice: We have both expanded and reduced our Service Area in
the State of Wisconsin for 2002.
We expanded our Service Area to
include the entire counties of Columbia, Dodge, Iowa, and Sauk.
We
eliminated from our Service Area the counties of Lafayette and
Walworth. If you live or work in one of these areas and do
not select
another FEHB plan, you will be covered only for emergency services received
outside the Service Area. In order to
receive full Plan benefits, you must
travel to a county in the remaining Service Area, and be seen by a Plan
provider.
This Plan has Excellent
accreditation from the NCQA.
See the 2002
Guide for more
information on the NCQA.
2002 Group Health Cooperative of South Central Wisconsin Table of Contents
2
Table of Contents
Introduction
............................................................................................................................................................................
4
Plain Language
......................................................................................................................................................................
4
Inspector General
Advisory....................................................................................................................................................
5
Section 1. Facts about this HMO
plan....................................................................................................................
6
How we pay providers
..........................................................................................................................
6
Who provides my health care?
..............................................................................................................
6
Your Rights
............................................................................................................................................
6
Service Area
..........................................................................................................................................
7
Section 2. How we change for 2002
......................................................................................................................
8
Program-wide changes
..........................................................................................................................
8
Changes to this Plan
..............................................................................................................................
8
Section 3. How you get care
..................................................................................................................................
9
Identification
cards................................................................................................................................
9
Where you get covered care
..................................................................................................................
9
Plan providers
....................................................................................................................................
9
Plan facilities
......................................................................................................................................
9
What you must do to get covered care
..................................................................................................
9
Primary
care........................................................................................................................................
9
Specialty care
......................................................................................................................................
9
Hospital care
....................................................................................................................................
10
Circumstances beyond our control
......................................................................................................
11
Services requiring our prior
approval..................................................................................................
11
Section 4. Your costs for covered services
..........................................................................................................
12
Copayments
......................................................................................................................................
12
Deductible
........................................................................................................................................
12
Coinsurance
......................................................................................................................................
12
Your catastrophic protection out-of-pocket
maximum........................................................................
12
Section 5. Benefits-Overview
..............................................................................................................................
13
(a) Medical services and supplies provided by
physicians and other health care professionals ........ 14
(b) Surgical and anesthesia services provided by physicians and
other health care professionals .... 22
(c) Services
provided by a hospital or other facility, and ambulance services
.................................. 25
(d) Emergency
services/ accidents
......................................................................................................
27
(e) Mental health and substance abuse
benefits..................................................................................
29 2
2 Page 3 4
2002 Group Health Cooperative of South Central Wisconsin Table of
Contents 3
(f) Prescription drug benefits
..........................................................................................................................
31
(g) Special features
..........................................................................................................................................
33
Services for deaf and hearing impaired
Centers of excellence for
transplants/ heart surgery/ etc.
(h) Dental
benefits............................................................................................................................................
34
Section 6. General exclusions things we don't
cover
..................................................................................................
35
Section 7. Filing a claim for covered services
..................................................................................................................
36
Section 8. The disputed claims process
............................................................................................................................
37
Section 9. Coordinating benefits with other
coverage
......................................................................................................
39
When you have
Other health coverage
....................................................................................................................................
39
Original Medicare
..........................................................................................................................................
40
Medicare managed care plan
........................................................................................................................
42
TRICARE/ Workers' Compensation/ Medicaid
................................................................................................
43
Other Government agencies
............................................................................................................................
43
When others are responsible for
injuries..........................................................................................................
43
Section 10. Definitions of terms we use in this
brochure
..................................................................................................
44
Section 11. FEHB facts
......................................................................................................................................................
45
Coverage
information......................................................................................................................................
45
No pre-existing condition
limitation..............................................................................................................
45
Where you can get information about enrolling in the FEHB Program
...................................................... 45
Types of
coverage available for you and your family
....................................................................................
45
When benefits and premiums start
................................................................................................................
46
Your medical and claims records are confidential
........................................................................................
46
When you
retire..............................................................................................................................................
46
When you lose benefits
....................................................................................................................................
46
When FEHB coverage ends
..........................................................................................................................
46
Spouse equity
coverage..................................................................................................................................
46
Temporary Continuation of Coverage (TCC)
................................................................................................
46
Converting to individual coverage
................................................................................................................
47
Getting a Certificate of Group Health Plan Coverage
..................................................................................
47
Long term care insurance is coming later in 2002
..............................................................................................................
48
Index
....................................................................................................................................................................................
49
Summary of benefits
............................................................................................................................................................
51
Rates
......................................................................................................................................................................
Back Cover 3
3 Page
4 5
2002 Group Health Cooperative of South Central Wisconsin Introduction/
Plain Language/ Advisory 4
Introduction
Group Health
Cooperative of South Central Wisconsin
8202 Excelsior Drive
Madison, WI
53717
This brochure describes the benefits of Group Health Cooperative of South
Central Wisconsin under our contract
(CS 1828) with the Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits
law. This brochure is the official statement of benefits. No oral statement
can modify or otherwise affect the benefits,
limitations, and exclusions of
this brochure.
If you are enrolled in this Plan, you are entitled to the benefits described
in this brochure. If you are enrolled for Self
and Family coverage, each
eligible family member is also entitled to these benefits. You do not have a
right to benefits
that were available before January 1, 2002, unless those
benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes
are effective January 1, 2002, and changes
are summarized on page 8. Rates
are shown at the end of this brochure.
Plain Language
Teams of government and health plans' staff worked
on all FEHB brochures to make them responsive, accessible, and
understandable to the public. For instance,
Except for necessary technical terms, we use common words. For instance,
"you" means the enrollee or family
member; "we" means Group Health
Cooperative of South Central Wisconsin.
We limit acronyms to ones you know. FEHB is the Federal Employees Health
Benefits Program. OPM is the Office of
Personnel Management. If we use
others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and
similar descriptions to help you
compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let OPM
know. Visit OPM's
"Rate Us" feedback area at www. opm. gov/ insure or e-mail OPM at
fehbwebcomments@ opm. gov. You may
also write to
OPM at the Office of Personnel Management, Office of Insurance
Planning and Evaluation Division,
1900 E Street,
NW, Washington, DC 20415. 4
4
Page 5 6
2002
Group Health Cooperative of South Central Wisconsin Introduction/ Plain
Language/ Advisory 5
Inspector General Advisory
Stop health care
fraud! Fraud increases the cost of health care for everyone. If you suspect
that a physician,
pharmacy, or hospital has charged you for services you did
not receive, billed you twice
for the same service, or misrepresented any
information, do the following:
Call the provider and ask for an explanation. There may be an error.
If the provider does not resolve the matter, call us at 608/ 828-4853 and
explain
the situation.
If we do not resolve the issue, call or write
THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
The United States
Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW, Room 6400
Washington, DC 20415
Penalties for fraud Anyone who falsifies a claim to obtain FEHB
Program benefits can be prosecuted for
fraud. Also, the Inspector General
may investigate anyone who uses an ID card if the
person tries to obtain
services for someone who is not an eligible family member, or is
no longer
enrolled in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 5
5 Page 6 7
2002 Group Health Cooperative of South Central Wisconsin Section 1 6
Section 1. Facts about this HMO plan
This Plan is a health
maintenance organization (HMO). We require you to see specific physicians,
hospitals, and other
providers that contract with us. These Plan providers
coordinate your health care services.
HMOs emphasize preventive care such as routine office visits, physical exams,
well-baby care, and immunizations, in
addition to treatment for illness and
injury. Our providers follow generally accepted medical practice when
prescribing
any course of treatment.
When you receive services from Plan providers, you will not have to submit
claim forms or pay bills. You only pay the
copayments and coinsurance
described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because
a particular provider is available.
You cannot change plans because a
provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract
with us.
How we pay providers
We contract with individual physicians,
medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be
responsible for your copayments or
coinsurance.
Who provides your health care?
GHC is a Group-Practice Prepayment
(GPP) plan. We select qualified, experienced doctors for our medical staff. The
group medical practice at GHC allows for in-house consultations, peer
review, and regular staff audits of medical care so
that we can assure
quality care for you and your family members.
The first and most important decision you must make is to select your primary
care provider. Specialists who represent
every possible specialty area also
serve GHC members. Your Primary Care Provider (PCP) makes any necessary
referrals, with the following exceptions: A woman may see her Plan
gynecological provider for her annual routine
examination without a referral
(certified nurse midwives are not covered providers under this Plan); Vision
care; Dental
care; Mental Condition benefits; Substance Abuse benefits; and
Chiropractic care.
GHC uses the facilities and services of four hospitals in the South Central
Wisconsin area. Your primary care site
(clinic) determines the assigned
hospital for your routine care. Most specialty care is referred to the
University of
Wisconsin Hospital and Clinics in Madison. Babies are usually
delivered at St. Marys Hospital in Madison.
Your rights
OPM requires that all FEHB Plans provide certain
information to their FEHB members. You
may get information about
us, our networks, providers, and facilities.
OPM's FEHB website (www. opm. gov/ insure) lists the specific types of
information that we must make available to you. Some of the required
information is listed below.
Years in existence: 26
Profit status: Non-Profit
Accreditation:
Excellent rating from NCQA
If you want more information about us, call 608/ 828-4827, or write to the
GHC Marketing Department, PO Box 44971,
Madison, WI 53744-4971. You may also contact us by fax at 608/ 828-9333
or visit our website at www. ghc-hmo. com. 6
6
Page 7 8
2002
Group Health Cooperative of South Central Wisconsin Section 1 7
Service area
To enroll in this Plan, you must live in or work
in our Service Area. This is where our providers practice. Our service
area
is:
In the state of Wisconsin, the entire counties of Columbia, Dane,
Dodge, Green, Iowa, Jefferson, Rock, and Sauk.
Ordinarily, you must get your
care from providers who contract with us. If you receive care outside of our
service area,
we will pay only for emergency care benefits. We will not pay
for any other health care services out of our service area
unless the
services have prior plan approval.
If you or a covered family member move outside of our service area, you can
enroll in another plan. If your dependents
live out of the area (for
example, if your child goes to college in another state), you should consider
enrolling in a
fee-for-service plan or an HMO that has agreements with
affiliates in other areas. If you or a family member move, you
do not have
to wait until Open Season to change plans. Contact your employing or retirement
office. 7
7 Page 8
9
2002 Group Health Cooperative of South Central
Wisconsin Section 2 8
Section 2. How we change for 2002
Do
not rely on these change descriptions; this page is not an official statement of
benefits. For that, go to Section 5 Benefits.
Also, we edited and clarified
language throughout the brochure; any language change not shown here is a
clarification that
does not change benefits.
Program-wide changes
We changed the address for sending disputed
claims to OPM. (Section 8)
Changes to this Plan
Your share of
the non-Postal premium will increase by 16.8% for Self Only or 26.7% for Self
and Family.
We now cover certain intestinal transplants. (Section 5( b))
We changed speech therapy benefits by removing the requirement that
services must be required to restore
functional speech. (Section 5( a))
We no longer limit total blood cholesterol tests to certain age groups.
(Section 5( a))
We now cover insulin pumps, under "Durable medical
equipment (DME)," subject to a member copay of 20% of
charges. (Section 5(
a))
We now cover Emergency care received in the outpatient department of a
hospital, both in and out of the service area, subject
to a member copay of
$25. If the emergency results in an admission as an inpatient, the $25 copay
will be waived. (Section
5( d))
We now cover Prescription drugs
prescribed by a Plan physician and obtained at a Plan pharmacy, for up to a 34
day
supply per prescription unit or refill, subject to the following copays:
A $6 copay per prescription unit or refilll for formulary generic
drugs, or for Plan approved Non-formulary generic drugs; and
A $12
copay per prescription unit or refill for formulary name brand drugs, or for
Plan approved Non-formulary
name brand drugs. (Section 5( f))
We now
cover the surgical removal of fully impacted teeth, under "Oral and
maxillofacial surgery," subject to a $10
copay per office visit. (Section 5(
b)).
We now cover physical exams required for travel, or for attending
school or camp, subject to a $10 copay. (Section 5( a))
We now cover
physician house visits subject to a $10 copay per visit. (Section 5( a))
We have removed the time restriction from Cardiac rehabilitation so that it no
longer must be provided over a 12 week
time period. (Section 5( a))
We
do not cover ambulance transportation to the home following an inpatient stay.
(Section 5( c) and 5( d))
We have added a "Not covered" section under
"Dental benefits" to show that except for an "Accidental injury benefit,"
we
do not cover any other dental services. (Section 5( h))
We have
both expanded and reduced our Service Area in the State of Wisconsin for 2002.
We have expanded our Service
Area to include the entire counties of
Columbia, Dodge, Iowa, and Sauk. We also have eliminated a portion of our
Service Area, so if you are enrolled in this Plan and live or work in one of
the following areas, you must select another
plan during Open Season to
continue to receive full Plan benefits: the partial counties of Lafayette (zip
codes 53504 and
53516) and Walworth (zip codes 53114, 53115, and 53190). If
you live or work in one of these areas and do not select
another FEHB plan,
you will be covered only for emergency services received outside the Service
Area. In order to
receive full Plan benefits, you must travel to a county in
the remaining Service Area, and be seen by a Plan provider.
(Brochure cover
and Section 1) 8
8 Page
9 10
2002 Group Health Cooperative of
South Central Wisconsin Section 3 9
Section 3. How you get care
Identification cards We will send you an identification (ID) card when
you enroll. You should carry your ID card with you at all times. You must show
it
whenever you receive services from a Plan provider, or fill a
prescription at a Plan pharmacy. Until you receive your ID card, use
your copy of the Health Benefits Election Form, SF-2809, your
health
benefits enrollment confirmation (for annuitants), or your
Employee Express
confirmation letter.
If you do not receive your ID card within 30 days after the effective
date of your enrollment, or if you need replacement cards, call us at
608/ 260-3170.
Where you get covered care You get care from "Plan providers" and
"Plan facilities." You will only pay copayments or coinsurance, and you will not
have to
file claims.
Plan providers Plan providers are
physicians and other health care professionals in
our service area that we
contract with to provide covered services to
our members. We credential Plan
providers according to
national standards.
We list Plan providers in the GHC provider directory, which we
update
periodically. The list is also on our website.
Plan facilities Plan facilities are hospitals and other facilities
in our service area
that we contract with to provide covered services to our
members.
We list these in the provider directory, which we update
periodically.
The list is also on our website.
What you must do It depends on the type of care you need. First, you
and each family to get covered care member must choose a primary care
physician. This decision is
important since your primary care physician
provides or arranges for
most of your health care. If you need assistance,
please call the GHC
Member Services Department at 608/ 828-4853.
Primary care Your primary care physician can be a family
practitioner, an internist
or a pediatrician. (You may also select from
affiliated nurse
practitioners or physicians assistants.) Your primary care
physician
will provide most of your health care, or give you a referral to
see
a specialist.
If you want to change primary care physicians or if your primary
care
physician leaves the Plan, call us. We will help you select a
new one.
Specialty care Your primary care physician will refer you to a
specialist for needed
care. When you receive a referral from your primary
care physician,
you must return to the primary care physician after the
consultation,
unless your primary care physician authorized a certain number
of
visits without additional referrals. The primary care physician must
provide or authorize all follow-up care. Do not go to the specialist for
return visits unless your primary care physician gives you a referral. 9
9 Page 10 11
2002 Group Health Cooperative of South Central
Wisconsin Section 3 10
However, you may see plan mental health and/ or
substance abuse,
vision care, dental care or chiropractic providers without
a referral,
and a woman may see her Plan gynecological provider for her
annual
routine examination without a referral.
Here are other things you should know about specialty care:
If you need
to see a specialist frequently because of a chronic,
complex, or serious
medical condition, your primary care
physician will develop a treatment plan
that allows you to see your
specialist for a certain number of visits
without additional
referrals. Your primary care physician will use our
criteria when
creating your treatment plan (the physician may have to get an
authorization or approval beforehand).
If you are seeing a specialist when you enroll in our Plan, talk to
your primary care physician. Your primary care physician will
decide
what treatment you need. If he or she decides to refer you
to a specialist,
ask if you can see your current specialist. If your
current specialist does
not participate with us, you must receive
treatment from a specialist who
does. Generally, we will not pay
for you to see a specialist who does not
participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan,
call your primary care physician, who will arrange for you to see
another specialist. You may receive services from your current
specialist until we can make arrangements for you to see
someone else.
If you have a chronic or disabling condition and lose access to your
specialist because we:
terminate our contract with your specialist for other than
cause; or
drop out of the Federal Employees Health Benefits
(FEHB)
Program and you enroll in another FEHB Plan; or
reduce
our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days
after you receive notice of the change. Contact us or, if we drop out
of
the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care,
even if it is beyond the 90 days.
Hospital care Your Plan primary care physician or specialist will
make necessary
hospital arrangements and supervise your care. This includes
admission to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins,
call
our Medical Utilization Management department immediately at
608/ 251-4156
x4514. If you are new to the FEHB Program, we will
arrange for you to
receive care. 10
10 Page
11 12
2002 Group Health Cooperative of
South Central Wisconsin Section 3 11
If you changed from another FEHB
plan to us, your former plan will
pay for the hospital stay until:
You are discharged, not merely moved to an alternative care
center; or
The day your benefits from your former plan run out; or
The 92nd day
after you become a member of this Plan, whichever
happens first.
These provisions apply only to the benefits of the hospitalized
person.
Circumstances beyond our control Under certain extraordinary
circumstances, such as natural disasters, we may have to delay your services or
we may be unable to
provide them. In that case, we will make all reasonable
efforts to
provide you with the necessary care.
Services requiring our Your primary care physician has authority to
refer you for most prior approval services. For certain services,
however, your physician must obtain
approval from us. Before giving
approval, we consider if the service
is covered, medically necessary, and
follows generally accepted
medical practice.
We call this review and approval process prior approval. Your
physician
must obtain prior approval for the following services:
Hospital care;
Referring you to a specialist;
Recommending follow-up
care;
All surgical procedures;
All physical, speech and occupational
therapy;
Infertility;
Breast reduction mammoplasty;
Plastic surgery;
Transplant of any organ;
All outpatient surgery; and
Growth hormone
therapy (GHT). 11
11 Page
12 13
2002 Group Health Cooperative of
South Central Wisconsin Section 4 12
Section 4. Your costs for
covered services
You must share the cost of some services. You are
responsible for:
Copayments A copayment is a fixed amount of money
you pay to the provider,
facility, pharmacy, etc., when you receive
services.
Example: When you see your primary care physician, you pay a
copayment of
$10 per office visit.
Deductible We do not have any deductible.
NOTE: If you change
plans during open season, you do not have to
start a new deductible under
your old plan between January 1, and the
effective date of your new plan. If
you change plans at another time
during the year, you must begin a new
deductible under your new plan.
Coinsurance Coinsurance is the percentage of our negotiated fee that
you must
pay for your care.
Example: In our Plan, you pay 20% of our allowance for insulin
pumps, and
50% of our allowance for sexual dysfunction drugs and for
preventive dental
care services if a non-participating dentist is used.
Your catastrophic protection We do not have an out-of-pocket maximum.
out-of-pocket maximum for
coinsurance and copayments 12
12 Page 13 14
2002 Group Health Cooperative of South Central Wisconsin Section 5 13
Section 5. Benefits-OVERVIEW (See page 8 for how our benefits
changed this year and page 51 for a benefits summary.)
NOTE: This
benefits section is divided into subsections. Please read the important things
you should keep in mind at
the beginning of each subsection. Also read the
General Exclusions in Section 6; they apply to the benefits in the
following
subsections. To obtain claims filing advice or
more information about our benefits, contact us at
608/ 828-4853 or at
our website at www. ghc-hmo. com.
(a) Medical services and supplies provided by physicians and other health
care professionals.................................... 14 21
Diagnostic
and treatment services Speech therapy
Lab, X-ray, and other diagnostic
tests Hearing services (testing, treatment, and supplies)
Preventive
care, adult Vision services (testing, treatment, and supplies)
Preventive care, children Foot care
Maternity care Orthopedic and
prosthetic devices
Family planning Durable medical equipment (DME)
Infertility services Home health services
Allergy care Chiropractic
Treatment therapies Alternative treatments
Physical and
occupational therapies Educational classes and programs
(b) Surgical and anesthesia services provided by physicians and other health
care professionals ................................ 22 24
Surgical
procedures Organ/ tissue transplants
Reconstructive surgery Anesthesia
Oral and maxillofacial surgery
(c) Services provided by a hospital or other facility, and ambulance services
.............................................................. 25 26
Inpatient hospital Hospice care
Outpatient hospital or ambulatory
Ambulance
surgical center
Extended care benefits/ skilled nursing care
facility benefits
(d) Emergency services/ accidents
..................................................................................................................................
27 28
Medical emergency Ambulance
(e) Mental health and substance abuse benefits
............................................................................................................
29 30
(f) Prescription drug
benefits..........................................................................................................................................
31 32
(g) Special features
..............................................................................................................................................................
33
Services for deaf and hearing impaired
Centers of excellence for
transplants/ heart surgery/ etc.
(h) Dental benefits
................................................................................................................................................................
34
Summary of benefits
............................................................................................................................................................
51 13
13 Page 14
15
2002 Group Health Cooperative of South Central
Wisconsin Section 5 (a) 14
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Section 5 (a). Medical services and supplies provided by physicians and
other health care professionals
Here are some important things to keep in
mind about these benefits:
Please remember that all benefits are
subject to the definitions, limitations,
and exclusions in this brochure and
are payable only when we determine they
are medically necessary.
Plan
physicians must provide or arrange your care.
We have no calendar year
deductible.
Be sure to read Section 4, Your costs for covered services,
for valuable
information about how cost sharing works. Also read Section
9 about
coordinating benefits with other coverage, including with Medicare.
Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians $10 per office visit
In physician's
office
In an urgent care center
Office medical consultations
Second surgical opinion
At home
Professional services of physicians Nothing
During a hospital stay
In a skilled nursing facility 14
14 Page 15 16
2002 Group
Health Cooperative of South Central Wisconsin Section 5 (a) 15
Lab,
X-ray and other diagnostic tests You pay
Tests, such as: Nothing if you
receive these
services during your office
Blood tests visit;
otherwise, $10 per
Urinalysis office visit
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG
Preventive care, adult You pay
Routine screenings, such as: $10
per office visit
Total Blood Cholesterol once every three years
Colorectal Cancer Screening, including
Fecal occult blood test
Sigmoidoscopy, screening every five years starting at age 50
Prostate Specific Antigen (PSA test) one annually for men age 40 and older
Routine pap test
Routine mammogram covered for women age 35 and older,
as follows:
From age 35 through 39, one during this five year period.
From age 40 through 64, one every calendar year
Physical exams required for travel, or for attending school or camp
Not covered: Physical exams required for obtaining or continuing All
charges.
employment or insurance.
Routine immunizations, limited to: $10 per office visit
Tetanus-diphtheria (Td) booster once every 10 years, ages 19 and
over
(except as provided for under Childhood immunizations)
Influenza/
Pneumococcal vaccines, annually, age 65 and over 15
15
Page 16 17
2002
Group Health Cooperative of South Central Wisconsin Section 5 (a) 16
Preventive care, children You pay
Childhood immunizations
recommended by the American Academy Nothing to age 5; $10 per
of Pediatrics
office visit age 5 and older
Well-child care charges for routine
examinations, immunizations and care
(up to age 22)
Examinations, such
as:
Eye exams through age 17 to determine the need for vision
correction
Ear exams through age 17 to determine the need for
hearing correction
Examinations done on the day of immunizations
(up to age 22)
Maternity care You pay
Complete maternity (obstetrical) care, such
as: $10 for the initial maternity
Prenatal care office visit; nothing for
all
Delivery other maternity related
Postnatal care office visits.
Note: Here are some things to keep in mind:
You may remain in the
hospital up to 48 hours after a regular delivery and
96 hours after a
cesarean delivery. We will extend your inpatient stay if
medically
necessary.
We cover routine nursery care of the newborn child during the
covered
portion of the mother's maternity stay. We will cover other care of
an
infant who requires non-routine treatment only if we cover the infant
under
a Self and Family enrollment.
We pay hospitalization and surgeon
services (delivery) the same as for
illness and injury. See Hospital
benefits (Section 5c) and Surgery
benefits (Section 5b).
Not covered: Routine sonograms to determine fetal age, size or sex All
charges
Family planning You pay
A broad range of voluntary
family planning services, limited to: $10 per office visit
Voluntary
sterilization
Surgically implanted contraceptives (such as Norplant)
Injectable contraceptive drugs (such as Depo provera)
Intrauterine devices
(IUDs)
Diaphragms
Note: We cover oral contraceptives under the
prescription drug benefit.
Not covered: Reversal of voluntary surgical sterilization, genetic
counseling All charges. 16
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2002 Group
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Infertility services You pay
Diagnosis and treatment of
infertility, such as: $10 per office visit
Artificial insemination:
Intracervical insemination (ICI)
Fertility drugs
Note: We only cover the oral fertility drug (clomiphene citrate) under the
prescription drug benefit.
Not covered: All charges.
Artificial insemination:
Intravaginal insemination (IVI)
Intrauterine
insemination (IUI)
Assisted reproductive technology (ART) procedures, such
as:
In vitro fertilization
Embryo
transfer, gamete GIFT and zygote ZIFT
Zygote transfer
Services and supplies related to excluded ART procedures
Cost of donor
sperm
Cost of donor egg
Injectable and oral fertility drugs, except
for Clomiphene citrate
Allergy care You pay
Testing and treatment $10 per office visit
Allergy injection
Allergy serum Nothing
Not covered: Provocative food testing and
sublingual All charges.
allergy desensitization
Treatment therapies You pay
Chemotherapy and radiation therapy
$10 per office visit
Note: High dose chemotherapy in association with
autologous bone marrow
transplants are limited to those transplants listed
under Organ/ Tissue
Transplants on page 24.
Respiratory and inhalation therapy
Dialysis Hemodialysis and
peritoneal dialysis
Intravenous (IV)/ Infusion Therapy Home IV and
antibiotic therapy
Growth hormone therapy (GHT)
Note: Growth hormone
is covered under the prescription drug benefit.
Note: We will only cover GHT
when we preauthorize the treatment.
Call your primary care physician for
preauthorization. If we determine that
GHT is not medically necessary, we
will not cover the GHT or related
services and supplies. See Services
requiring our prior approval in Section 3. 17
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2002
Group Health Cooperative of South Central Wisconsin Section 5 (a) 18
Physical and occupational therapies You pay
60 consecutive
days per condition for the services of each of the following: $10 per initial
visit per
qualified physical therapists; and condition; nothing
during
occupational therapists. inpatient admission
Note: We
only cover therapy to restore bodily function when there
has been a total or
partial loss of bodily function due to illness or injury.
One follow-up visit six months after the date of your last physical or $10
per visit
occupational therapy treatment.
Cardiac rehabilitation following a heart transplant, bypass surgery, a $10
for the initial visit
myocardial infarction, unstable angina pectoris, or
angioplasty is provided
for up to 36 sessions.
Not covered: All charges.
Long-term rehabilitative therapy
Exercise programs (except in therapy programs listed above)
Speech therapy You pay
60 consecutive days per condition for the
services of qualified $10 per initial office visit
speech therapists. per
condition; nothing during
inpatient admission
Hearing services (testing, treatment, and supplies) You pay
Hearing testing Nothing to age 5; $10 per
office visit for age 5 and older
Not covered: Hearing aids, testing and examinations for them All charges.
Vision services (testing, treatment, and supplies) You pay
Annual vision examinations Nothing to age 5; $10 per
office visit for age 5
and older
Annual eye refractions Nothing
Lenses following intraocular surgery (such as for cataract removal) or $10
per office visit
for Keratoconus when there is a change in visual acuity
requiring a
new prescription
Vision services continued on the next page. 18
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2002 Group Health Cooperative of South Central
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Vision services (testing, treatment, and
supplies) You pay
(Continued)
Not covered: All charges.
Eyeglasses or contact lenses, except as
above
Eye exercises and orthoptics
Radial keratotomy and other
refractive surgery
Foot care You pay
Routine foot care when you are under active
treatment for a metabolic or $10 per office visit
peripheral vascular
disease, such as diabetes.
See orthopedic and prosthetic devices for information on podiatric
shoe
inserts.
Not covered: All charges.
Cutting, trimming or removal of corns,
calluses, or the free edge of toenails,
and similar routine treatment of
conditions of the foot, except as stated above
Treatment of weak, strained
or flat feet or bunions or spurs; and of any
instability, imbalance or
subluxation of the foot (unless the treatment is by
open cutting surgery)
Orthopedic and prosthetic devices You pay
Artificial limbs and
eyes, stump hose $10 per office visit
Externally worn breast prostheses
and surgical bras, including necessary
replacements, following a mastectomy
Internal prosthetic devices, such as artificial joints, pacemakers, and
surgically implanted breast implant following mastectomy.
Note: See
Section 5( b) for coverage of the surgery to insert the device.
Braces
Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome
Not covered: All charges.
Orthopedic and corrective shoes
Arch
supports
Foot orthotics
Heel pads and heel cups
Lumbosacral
supports
Corsets, trusses, elastic stockings, support hose, and other
supportive devices
Cost of a cochlear implanted device
Prosthetic
replacements, unless the item is no longer useful and has exceeded
its
reasonable lifetime under normal use; or the member's condition has
changed
so as to make the original equipment inappropriate. 19
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2002 Group Health Cooperative of South Central
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Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of
durable $10 per office visit
medical equipment prescribed by your Plan
physician, such as oxygen and
dialysis equipment. Under this benefit, we
also cover:
hospital beds;
standard wheelchairs;
crutches;
walkers; and
blood glucose monitors
insulin pumps. 20% copay
Note: Call us at 608/ 251-4156 x4514 as soon
as your Plan physician
prescribes any of the above equipment. We will
arrange with a health care
provider to rent or sell you durable medical
equipment at discounted rates and
will tell you more about this service when
you call.
Not covered: All charges.
Motorized wheel chairs
DME
replacements, unless the item is no longer useful and has exceeded its
reasonable lifetime under normal use; or the member's condition has
changed so as to make the original equipment inappropriate.
Home health services You pay
Home health care ordered by a Plan
physician and provided by a registered Nothing
nurse (R. N.), licensed
practical nurse (L. P. N.), licensed vocational nurse
(L. V. N.), or home
health aide.
Services include oxygen therapy, intravenous therapy and
medications.
Not covered: All charges.
Nursing care requested by, or for the
convenience of, the patient or the
patient's family;
Home care
primarily for personal assistance that does not include a medical
component
and is not diagnostic, therapeutic, or rehabilitative 20
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2002 Group Health Cooperative of South Central
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Chiropractic You pay
Chiropractic services, but only related to a specific injury. $10 per office
visit
Not covered: All charges.
Chiropractic services for chronic problems
or for maintenance.
Alternative treatments You pay
Not covered: All charges.
Acupuncture
Naturopathic services
Hypnotherapy
Biofeedback
Educational classes and programs You pay
Coverage may include:
Some fees required contact
Smoking Cessation GHC Health Education
Diabetes self-management Department at 608/ 257-9705
Nutrition for fees
and schedules
Weight Management
Stress Management
Prenatal
First aid
Fitness programs 21
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Section 5 (b). Surgical and anesthesia services provided by physicians
and other health care professionals
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions,
limitations,
and exclusions in this brochure and are payable only when we
determine
they are medically necessary.
Plan physicians must provide
or arrange your care.
We have no calendar year deductible.
Be sure
to read Section 4, Your costs for covered services, for valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other
health care professional for your surgical care. Look in Section 5( c) for
charges associated with the facility (i. e., hospital, surgical center,
etc.).
YOUR PLAN DOCTOR MUST GET PRIOR APPROVAL OF SOME
SURGICAL
PROCEDURES. Please refer to the prior approval information
shown in Section
3 to be sure which services require prior approval and
identify which
surgeries require prior approval.
Benefit Description You pay
Surgical procedures
A comprehensive range of services such as: $10 per office visit;
Operative procedures nothing for hospital visit
Treatment of fractures,
including casting
Normal pre-and post-operative care by the surgeon
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy
procedures
Removal of tumors and cysts
Correction of congenital
anomalies (see reconstructive surgery)
Surgical treatment of morbid
obesity a condition in which an individual
weighs 100 pounds or 100% over
his or her normal weight according to
current underwriting standards;
eligible members must be age 18 or over
Insertion of internal prosthetic
devices. See Section 5( a) Orthopedic and
prosthetic devices for device
coverage information.
Voluntary sterilization
Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according to where
the procedure is done. For example, we pay Hospital benefits for a pacemaker
and Surgery benefits for insertion of the pacemaker.
Not covered: All charges.
Reversal of voluntary sterilization
Routine treatment of conditions of the foot; see Foot care 22
22 Page 23 24
2002 Group Health Cooperative of South Central
Wisconsin Section 5 (b) 23
Reconstructive surgery You pay
Surgery to correct a functional defect $10 per office visit;
Surgery to
correct a condition caused by injury or illness if: nothing for hospital visit
the condition produced a major effect on the member's appearance
and
the condition can reasonably be expected to be corrected by
such surgery
Surgery to correct a condition that existed at or from birth
and is a
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate;
birth marks; webbed fingers; and webbed toes.
All stages of
breast reconstruction surgery following a mastectomy, such as:
surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas;
breast prostheses and surgical bras and replacements
(see Prosthetic
devices)
Note: If you need a mastectomy, you may choose to have the
procedure
performed on an inpatient basis and remain in the hospital up to
48 hours
after the procedure.
Not covered: All charges
Cosmetic surgery any surgical procedure
(or any portion of a procedure)
performed primarily to improve physical
appearance through change in
bodily form, except repair of accidental injury
Surgeries related to sex transformation
Oral and maxillofacial surgery You pay
Oral surgical procedures,
limited to: $10 per office visit;
Reduction of fractures of the jaws or
facial bones; nothing for hospital visit
Surgical correction of cleft lip,
cleft palate or severe functional malocclusion;
Removal of stones from
salivary ducts;
Excision of leukoplakia or malignancies;
Excision of
cysts and incision of abscesses when done as independent
procedures;
Other surgical procedures that do not involve the teeth or their
supporting
structures; and
Surgical removal of fully impacted teeth.
Dental treatment of Temporomandibular joint (TMJ) syndrome is limited $10
per office visit
to a maximum Plan payment of $1250 per person per calendar
year.
Not covered: All charges.
Oral implants and transplants
Procedures that involve the teeth or their supporting structures
(such as
the periodontal membrane, gingiva, and alveolar bone) 23
23 Page 24 25
2002 Group Health Cooperative of South Central
Wisconsin Section 5 (b) 24
Organ/ tissue transplants You pay
Limited to: $10 per office visit
Cornea for evaluation;
Heart nothing in hospital
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single/ Double
Pancreas
Allogenic (donor)
bone marrow transplants
Autologous bone marrow transplants (autologous
stem cell and peripheral
stem cell support) for the following conditions:
acute lymphocytic or
non-lymphocytic leukemia; advanced Hodgkin's lymphoma;
advanced
non-Hodgkin's lymphoma; advanced neuroblastoma; breast cancer;
multiple
myeloma; epithelial ovarian cancer; and testicular, mediastinal,
retroperitoneal and ovarian germ cell tumors
Intestinal transplants
(small intestine) and the small intestine with the liver or
small intestine
with multiple organs such as the liver, stomach, and pancreas
National
Transplant Program (NTP) UW Hospital & Clinics
Limited Benefits Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved by
the
Plan's medical director in accordance with the Plan's protocols.
Note: We cover related medical and hospital expenses of the donor when we
cover the recipient.
Not covered: All charges
Donor screening tests and donor search
expenses, except those performed
for the actual donor
Implants of
artificial organs
Transplants not listed as covered
Anesthesia You pay
Professional services provided in Nothing
Hospital (inpatient)
Professional services provided in $10 per visit
Hospital outpatient
department
Skilled nursing facility
Ambulatory surgical center
Office 24
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Section 5 (c). Services provided by a hospital or other facility,
and
ambulance services
Here are some important things to remember about these benefits:
Please remember that all benefits are subject to the definitions, limitations,
and exclusions in this brochure and are payable only when we determine they
are medically necessary.
Plan physicians must provide or arrange your
care and you must be
hospitalized in a Plan facility.
Be sure to read
Section 4, Your costs for covered services, for valuable
information
about how cost sharing works. Also read Section 9 about
coordinating
benefits with other coverage, including with Medicare.
The amounts listed
below are for the charges billed by the facility (i. e.,
hospital or
surgical center) or ambulance service for your surgery or care.
Any costs
associated with the professional charge (i. e., physicians, etc.) are
covered in Section 5( a) or (b).
Benefit Description You pay
Inpatient hospital
Room and board, such as Nothing
ward, semiprivate, or intensive care
accommodations;
general nursing care; and
meals and special diets.
NOTE: If you want a private room when it is not medically necessary, you
pay the additional charge above the semiprivate room rate.
Other hospital services and supplies, such as:
Operating, recovery,
maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood
products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and
equipment, including oxygen
Anesthetics, including nurse anesthetist
services
Take-home items
Medical supplies, appliances, medical
equipment, and any covered items
billed by a hospital for use at home
Not covered: All charges.
Custodial care
Non-covered
facilities, such as nursing homes, schools
Personal comfort items, such as
telephone, television, barber services,
guest meals and beds
Private
nursing care 25
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2002 Group Health Cooperative of
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Outpatient hospital or
ambulatory surgical center You pay
Operating, recovery, and other
treatment rooms Nothing
Prescribed drugs and medicines
Diagnostic
laboratory tests, X-rays, and pathology services
Administration of blood,
blood plasma, and other biologicals
Blood and blood plasma, if not donated
or replaced
Pre-surgical testing
Dressings, casts, and sterile tray
services
Medical supplies, including oxygen
Anesthetics and
anesthesia service
NOTE: We cover hospital services and supplies related to
dental procedures
when necessitated by a non-dental physical impairment. We
do not cover the
dental procedures.
Not covered: Blood and blood derivatives not replaced by the member All
charges
Extended care benefits/ skilled nursing care You pay
facility benefits
We provide a comprehensive range of benefits for up to a 100 days per Nothing
calendar year when full-time skilled nursing care is necessary and
confinement
in a skilled nursing facility is medically appropriate as
determined by a Plan
doctor and approved by the Plan.
Not covered: Custodial care All charges
Hospice care You pay
Supportive and palliative care for a terminally ill member is covered in
Nothing
the home. Services include outpatient care and family counseling;
these
services are provided under the direction of a Plan doctor who
certifies that
the patient is in the terminal stage of an illness, with a
life expectancy of six
months or less.
Not covered: Independent nursing, homemaker services All charges
Ambulance You pay
Local professional ambulance service when
medically appropriate Nothing
Not covered: Ambulance services to home following an inpatient stay All
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Section 5 (d). Emergency services/ accidents
Here are some important
things to keep in mind about these benefits:
Please remember that all
benefits are subject to the definitions, limitations,
and exclusions in this
brochure.
We have no calendar year deductible.
Be sure to read
Section 4, Your costs for covered services, for valuable
information
about how cost sharing works. Also read Section 9 about
coordinating
benefits with other coverage, including with Medicare.
What is a medical emergency?
A medical emergency is the sudden and
unexpected onset of a condition or an injury that you believe endangers
your
life or could result in serious injury or disability, and requires immediate
medical or surgical care. Some
problems are emergencies because, if not
treated promptly, they might become more serious; examples include
deep cuts
and broken bones. Others are emergencies because they are potentially life
threatening, such as heart
attacks, strokes, poisonings, gunshot wounds, or
sudden inability to breathe. There are many other acute
conditions that we
may determine are medical emergencies what they all have in common is the need
for
quick action.
What to do in case of emergency:
Emergencies within our service area:
If you are in an emergency situation, please call your primary care doctor.
In extreme emergencies, if you are unable to contact your doctor, contact the
nearest emergency
system (e. g., the 911 telephone system) or go to the
nearest hospital emergency room. Be sure to tell
emergency room personnel
that you are a GHC Plan member so they can notify us. You or a family member
must also notify us within 48 hours. It is your responsibility to make
certain that the Plan has been notified.
If you need to be hospitalized in a non-Plan facility, you or a family member
must notify the Plan within 48
hours or on the first working day following
your admission, unless it is not reasonably possible to do so. If a
GHC plan
doctor believes that you will receive better care in a Plan hospital, we will
transfer you when it is
medically feasible and we will pay all ambulance
charges for the transfer.
Benefits are available for care by non-Plan providers in a medical emergency
only if delay in reaching a Plan
provider would result in death, disability
or significant jeopardy to your condition.
Any follow up care recommended by non-plan providers in such a medical
emergency must be approved by
GHC or provided by GHC plan providers.
Emergencies outside our service area: Benefits are available for any
medically necessary health service that is immediately required because of
injury or unforeseen illness.
If you need to be hospitalized, you or a family member must notify the Plan
within 48 hours or on the first
working day following your admission, unless
it is not reasonably possible to do so. If a GHC Plan doctor
believes you
will receive better care in a Plan hospital, we will transfer you when it is
medically feasible and we
will pay all ambulance charges for that transfer.
Any follow-up care recommended by non-plan providers in such a medical
emergency must be approved by
GHC or provided by GHC plan providers. 27
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2002 Group Health Cooperative of South Central
Wisconsin Section 5 (d) 28
Benefit Description You pay
Emergency
within our service area
Emergency care at a doctor's office $10 per visit
Emergency care at an urgent care center Nothing
Emergency care as an
inpatient at a hospital, including doctors' services
Emergency care as an outpatient at a hospital, including doctors' services
$25 per visit, waived if
admitted as an inpatient.
Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
Emergency care at a
doctor's office $10 per visit
Emergency care at an urgent care center Nothing
Emergency care as an
inpatient at a hospital, including doctors' services
Emergency care as an outpatient at a hospital, including doctors' services
$25 per visit, waived if
admitted as an inpatient.
Not covered: All charges.
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care
could
have been foreseen before leaving the service area
Medical and hospital
costs resulting from a normal full-term delivery of a
baby outside the
service area
Ambulance
Professional ambulance service, as well as air
ambulance, when Nothing
medically appropriate.
See Section 5( c) for non-emergency service.
Not covered: Ambulance services to home following an inpatient stay All
charges. 28
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Section 5 (e). Mental health and substance abuse benefits
When you
get our approval for services and follow a treatment plan we approve,
cost
sharing and limitations for Plan mental health and substance abuse benefits
will be no greater than for similar benefits for other illnesses and
conditions.
Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and
exclusions in
this brochure.
Be sure to read Section 4, Your costs
for covered services, for valuable
information about how cost sharing
works. Also read Section 9 about
coordinating benefits with other coverage,
including with Medicare.
Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider and Your
cost sharing
contained in a treatment plan that we approve. The treatment
plan may include responsibilities are no
services, drugs and supplies
described elsewhere in this brochure. greater than for other
illnesses or
conditions.
Note: Plan benefits are payable only when we determine the care
is clinically
appropriate to treat your condition and only when you receive
the care as part
of a treatment plan that we approve.
Professional services, including individual or group therapy by providers
$10 per office visit
such as psychiatrists, psychologists, or
clinical-social workers.
Medication management
Diagnostic tests Nothing if you receive
these services during your
office visit; otherwise,
$10 per office visit
Services provided by a hospital or other facility Nothing
Services in
approved alternative care settings such as partial hospitalization,
full-day
hospitalization, facility based intensive outpatient treatment.
Mental health and substance abuse benefits continued on next page Mental
health and substance abuse benefits continued on next page 29
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2002 Group Health Cooperative of South Central
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Mental health and substance abuse benefits
(continued) You Pay
Not covered: Services we have not
approved. All charges.
NOTE: OPM will base its review of disputes about
treatment plans on the
treatment plan's clinical appropriateness. OPM will
generally not order us to
pay or provide one clinically appropriate
treatment plan in favor of another.
Preauthorization To be eligible to receive these benefits you must
obtain a treatment plan and follow all of our network authorization processes.
Patients may make their own appointments for mental health and/ or
substance
abuse services as follows:
Outpatient Mental Health GHC Mental Health Department
Telephone: 608/
257-1204 or 800/ 605-4327
Inpatient Mental Health US Hospital & Clinics
Substance Abuse
Outpatient and Inpatient Services
Gateway Recovery Services, Inc.
608/
278-8200 (Madison, WI)
608/ 877-1855 (Stoughton, WI)
Limitation We may limit your benefits if you do not obtain a treatment
plan. 30
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Section 5 (f). Prescription drug benefits
Here are some important
things to keep in mind about these benefits:
We cover prescribed drugs
and medications, as described in the chart
beginning on the next page.
All benefits are subject to the definitions, limitations and exclusions in
this brochure and are payable only when we determine they are
medically
necessary.
Be sure to read Section 4, Your costs for covered services, for
valuable
information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
There are important features you should be aware of. These include:
Who can write your prescription. A plan physician, referral doctor,
or
licensed dentist must write the prescription.
Where you can obtain them. You must fill the prescription at a
plan pharmacy.
We use a formulary. A drug formulary is a list of prescription
medications
representing the current judgment of medical practitioners for
the treatment of
disease. Not all medications will be listed in the
formulary, particularly when
there are several similar medications
available. The formulary will include the
drugs covered by the plan's
benefit. Your physician/ practitioner may request
coverage for non-formulary
drugs when clinically necessary.
There are dispensing limitations. We furnish up to a 34-day supply of
the
prescribed drug, or one commercially prepared unit (such as one vial of
opthalmic drops, one inhaler, or one bottle of insulin). There are certain
drugs
that we will cover up to a 100 day supply. You pay $6 copay for each
generic and
$12 copay for each name brand prescription, for up to a 34-day
supply.
If coverage has been approved for a non-formulary drug, you pay the
applicable
generic or name brand copayment. For non-formulary drugs when
coverage has
not been approved, the copayment is equal to the
plan-calculated total
prescription cost.
Why use generic drugs? Generic drugs offer a safe and economic way
to meet
your prescription drug needs. The generic name of a drug is its
chemical name;
the name brand is the name under which the manufacturer
advertises and sells a
drug. Under federal law, generic and name brand drugs
must meet the same
standards for safety, purity, strength, and
effectiveness. A generic prescription
costs you less and helps moderate the
costs of providing healthcare.
When you have to file a claim. Generally you will not need to file a
claim.
An exception would be a drug prescribed in an emergency or urgent
situation
when you are out of the area. Forward such claims to GHC Claims
Department,
PO Box 44971, Madison, WI 53744-4971. Be sure to include your
member
number and an explanation of why you are submitting the claim.
Prescription drug benefits begin on the next page. Prescription drug
benefits begin on the next page. 31
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2002 Group
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Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician, A $6 copay for generic drugs
referral doctor, or licensed
dentist, and obtained from a Plan pharmacy. A $12 copay for
Drugs and
medicines that by Federal law of the United States require a name brand drugs
physician's prescription for their purchase, except those listed as Not
covered. Note: if there is no generic
Insulin equivalent available,
you will
Diabetic supplies, including insulin syringes, needles,
injection pens, glucose still have to pay the
test tablets and test
tape, Bendict's solution or equivalent and acetone name brand copay.
test tablets
Contraceptive drugs and devices
Smoking
cessation drugs when participating in the Plan's behavior
modification
program
Prenatal vitamins during pregnancy
Disposable needles and
syringes for the administration of covered medications
Oral fertility
drug, Clomiphene citrate, limited to a lifetime maximum of
one year
Drugs for sexual dysfunction are subject to dosage limits. 50%
Contact
plan for details.
Not covered: All Charges
Drugs and supplies for cosmetic purposes
Non-formulary drugs
Drugs to enhance athletic performance
Fertility drugs, including drugs to maintain pregnancy (except Clomiphene
citrate see covered medications)
Drugs obtained at a non-Plan
pharmacy except for out-of-area emergencies
Vitamins, nutrients, and food
supplements even if a physician prescribes or
administers them (except
prenatal vitamins see covered medications)
Non-prescription medications
Drugs for which there is a nonprescription equivalent available
Medical supplies such as dressings and antiseptics
Smoking cessation drugs
(except when participating in the Plan's behavior
modification program)
Weight loss drugs, appetite suppressants, weight loss programs or classes,
except when medically necessary for the treatment of morbid obesity 32
32 Page 33 34
2002 Group Health Cooperative of South Central
Wisconsin Section 5 (g) 33
Section 5 (g). Special features
Feature Description
Services for deaf and Hearing impaired interpreter for non-emergency
services can be reached at this hearing impaired TDD line: 608/ 257-7391.
Centers of excellence Our local center of excellence is associated
with the University of Wisconsin for transplants/ heart Hospital and
Clinics in Madison, Wisconsin.
surgery/ etc. 33
33 Page 34 35
2002 Group Health Cooperative of South Central
Wisconsin Section 5 (h) 34
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Section 5 (h). Dental benefits
Here are some important things to keep
in mind about these benefits:
Please remember that all benefits are
subject to the definitions, limitations,
and exclusions in this brochure and
are payable only when we determine they
are medically necessary.
Plan
dentists must provide or arrange your care.
We have no calendar year
deductible.
We cover hospitalization for dental procedures only when a
nondental physical
impairment exists which makes hospitalization necessary
to safeguard the
health of the patient; we do not cover the dental procedure
unless it is
described below.
Be sure to read Section 4, Your costs
for covered services, for valuable
information about how cost sharing
works. Also read Section 9 about
coordinating benefits with other coverage,
including with Medicare.
Accidental injury benefit You pay
We cover restorative services
and supplies necessary to promptly repair and Nothing up to $1500 per
replace sound natural teeth. The need for these services must result from an
accident, all charges above
accidental injury. You must be seen within 48
hours of the accident; however, $1500 per accident
treatment may be delayed
due to your medical condition. Damage to teeth
caused by chewing or biting
does not constitute an accidental injury.
Dental benefits
Service You pay
Prophylaxis or cleaning (one every six months) Nothing if you use a GHC
Topical applications of fluoride through age fifteen (one every six
months) Plan dentist; 50% of charges
if you use a non-participating
dentist.
Not covered: all other dental services (i. e., fillings, extractions,
crowns, All charges.
orthodontics, etc.) 34
34
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2002
Group Health Cooperative of South Central Wisconsin Section 6 35
Section 6. General exclusions things we don't cover
The
exclusions in this section apply to all benefits. Although we may list a
specific service as a benefit, we will
not cover it unless your Plan doctor
determines it is medically necessary to prevent, diagnose, or treat your
illness, disease, injury, or condition, and we agree, as discussed under
What Services Require Our Prior Approval
on page 11.
We do not cover the following:
Care by non-Plan providers except for
authorized referrals or emergencies (see Emergency Benefits);
Services,
drugs, or supplies you receive while you are not enrolled in this Plan;
Services, drugs, or supplies that are not medically necessary;
Services,
drugs, or supplies not required according to accepted standards of medical,
dental, or
psychiatric practice;
Experimental or investigational procedures, treatments, drugs or devices;
Services, drugs, or supplies related to abortions, except when the life of
the mother would be endangered
if the fetus were carried to term or when the
pregnancy is the result of an act of rape or incest;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from
the FEHB Program. 35
35 Page
36 37
2002 Group Health Cooperative of
South Central Wisconsin Section 7 36
Section 7. Filing a claim for
covered services
When you see Plan physicians, receive services at Plan
hospitals and facilities, or fill your prescription drugs at Plan
pharmacies, you will not have to file claims. Just present your
identification card and pay your copayment or
coinsurance, if applicable.
You will only need to file a claim when you receive emergency services from
non-plan providers. Sometimes these
providers bill us directly. Check with
the provider. If you need to file the claim, here is the process:
Medical, hospital and drug benefits In most cases, providers and
facilities file claims for you. Physicians must file on the form HCFA-1500,
Health Insurance
Claim Form. Facilities will file on the UB-92 form. For
claims
questions and assistance, call us at 608/ 828-4853.
When you must file a claim such as for out-of-area care
submit it on
the HCFA-1500 or a claim form that includes the
information shown below.
Bills and receipts should be itemized
and show:
Covered member's name, ID number, and Social Security Number;
Name
and address of the physician or facility that provided the
service or
supply;
Dates you received the services or supplies;
Diagnosis;
Type of each service or supply;
The charge for each service or
supply;
A copy of the explanation of benefits, payments, or denial from
any
primary payer such as the Medicare Summary Notice (MSN); and
Receipts, if you paid for your services.
Submit your claims to: Group Health Cooperative, Claims
Department, PO
Box 44971, Madison, WI 53744-4971.
Deadline for filing your claim Send us all of the documents for your
claim as soon as possible. You must submit the claim by December 31 of the year
after the year you
received the service, unless timely filing was prevented
by
administrative operations of government or legal incapacity,
provided
the claim was submitted as soon as reasonably possible.
When we need more information Please reply promptly when we ask for
additional information. We may delay processing or deny your claim if you do not
respond. 36
36 Page
37 38
2002 Group Health Cooperative of
South Central Wisconsin Section 8 37
Section 8. The disputed claims
process
Follow this Federal Employees Health Benefits Program disputed
claims process if you disagree with our decision on
your claim or request
for services, drugs, or supplies including a request for preauthorization:
Step Description
1 Ask us in writing to reconsider our initial decision. You must: (a)
Write to us within 6 months from the date of our decision; and
(b) Send your
request to us at: Group Health Cooperative Member Services, PO Box 44971,
Madison, WI
53744-4971; and
(c) Include a statement about why you
believe our initial decision was wrong, based on specific benefit
provisions
in this brochure; and
(d) Include copies of documents that support your
claim, such as physicians' letters, operative reports, bills,
medical
records, and explanation of benefits (EOB) forms.
2 We have 30 days from the date we receive your request to: (a) Pay
the claim (or, if applicable, arrange for the health care provider to give you
the care); or
(b) Write to you and maintain our denial go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider,
we will send you a copy of our
request go to step 3.
3 You or your provider must send the information so that we receive it
within 60 days of our request. We will then decide within 30 more days.
If
we do not receive the information within 60 days, we will decide within 30 days
of the date the information
was due. We will base our decision on the
information we already have.
We will write to you with our decision.
4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
90 days after the date of our letter
upholding our initial decision; or
120 days after you first wrote to us
if we did not answer that request in some way within 30 days; or
120 days
after we asked for additional information.
Write to OPM at: Office of Personnel Management, Office of Insurance
Programs, Contracts Division 3,
1900 E Street NW, Washington, DC 20415-3630.
Step 4 continued on next page 37
37
Page 38 39
2002
Group Health Cooperative of South Central Wisconsin Section 8 38
Send
OPM the following information:
A statement about why you believe our
decision was wrong, based on specific benefit provisions in
this brochure;
Copies of documents that support your claim, such as physicians' letters,
operative reports, bills, medical
records, and explanation of benefits (EOB)
forms;
Copies of all letters you sent to us about the claim;
Copies
of all letters we sent to you about the claim; and
Your daytime phone
number and the best time to call.
Note: If you want OPM to review different claims, you must clearly identify
which documents apply to
which claim.
Note: You are the only person who has a right to file a disputed claim with
OPM. Parties acting as your
representative, such as medical providers, must
include a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to
meet the deadline because of
reasons beyond your control.
5 OPM will review your disputed claim request and will use the
information it collects from you and us to decide whether our decision is
correct. OPM will send you a final decision within 60 days. There are no other
administrative appeals.
6 If you do not agree with OPM's decision, your only recourse is to
sue. If you decide to sue, you must file the suit against OPM in Federal court
by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies. This is the only deadline that may not be
extended.
OPM may disclose the information it collects during the review
process to support their disputed claim
decision. This information will
become part of the court record.
You may not sue until you have completed the disputed claims process.
Further, Federal law governs your
lawsuit, benefits, and payment of
benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may
recover only the amount of
benefits in dispute.
NOTE: If you have a serious or life threatening condition (one that
may cause permanent loss of bodily functions or
death if not treated as soon
as possible), and
(a) We haven't responded yet to your initial request for care or
preauthorization/ prior approval, then call us at
608/ 828-4853 and we will
expedite our review; or
(b) We denied your initial request for care or
preauthorization/ prior approval, then:
If we expedite our review and
maintain our denial, we will inform OPM so that they can give your claim
expedited
treatment too, or
You can call OPM's Health Benefits
Contracts Division 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time.
38
38 Page 39 40
2002 Group Health Cooperative of South Central
Wisconsin Section 9 39
Section 9. Coordinating benefits with other
coverage
When you have other health coverage You must tell us if you are
covered or a family member is covered under another group health plan or have
automobile insurance that
pays health care expenses without regard to fault.
This is called
"double coverage."
When you have double coverage, one plan normally pays its benefits
in
full as the primary payer and the other plan pays a reduced benefit
as the
secondary payer. We, like other insurers, determine which
coverage is
primary according to the National Association of
Insurance Commissioners'
guidelines.
When we are the primary payer, we will pay the benefits described in
this
brochure.
When we are the secondary payer, we will determine our allowance.
After
the primary plan pays, we will pay what is left of our allowance,
up to our
regular benefit. We will not pay more than our allowance.
What is Medicare? Medicare is a Health Insurance Program for: People
65 years of age and older.
Some people with disabilities, under 65 years
of age.
People with End-Stage Renal Disease (permanent kidney failure
requiring dialysis or a transplant)
Medicare has two parts:
Part A (Hospital Insurance). Most people do not
have to pay
for Part A. If you or your spouse worked for at least 10 years
in
Medicare-covered employment, you should be able to qualify for
premium-free Part A insurance. (Someone who was a federal
employee on
January 1, 1983, or since automatically qualifies.)
Otherwise, if you are
age 65 or older, you may be able to buy it.
Contact 1-800-MEDICARE for more
information.
Part B (Medical Insurance). Most people pay monthly for Part
B.
Generally, Part B premiums are withheld from your monthly Social
Security check or your retirement check.
If you are eligible for Medicare, you may have choices in how you
get
your health care. Medicare + Choice plan is the term used to
describe the
various health plan choices available to Medicare
beneficiaries. The
information in the next few pages shows how we
coordinate benefits with
Medicare, depending on the type of
Medicare managed care plan you have. 39
39 Page 40 41
2002 Group Health Cooperative of South Central
Wisconsin Section 9 40
Section 9. Coordinating benefits with other
coverage (continued)
The Original Medicare Plan The
Original Medicare Plan is a plan that is available everywhere in
(Part A
or Part B) the United States. It is the way everyone used to get Medicare
benefits
and is the way most people get their Medicare Part A and Part B
benefits
now. You may go to any doctor, specialist or hospital that accepts
Medicare. The Original Medicare Plan pays its share and you pay your
share. Some things are not covered under Original Medicare, like
prescription drugs.
When you are enrolled in Original Medicare along with this plan,
you
still need to follow the rules in this brochure for us to cover your
care.
Your care must continue to be authorized by your Plan primary
care
physician.
We will not waive any of our copayments or coinsurance.
(Primary payer
chart begins on next page.) 40
40 Page 41 42
2002 Group
Health Cooperative of South Central Wisconsin Section 9 41
The following
chart illustrates whether the Original Medicare Plan or this Plan should
be the primary payer for you
according to your employment status and other
factors determined by Medicare. It is critical that you tell us if you or a
covered family member has Medicare coverage so we can administer these
requirements correctly.
Primary Payer Chart
A. When either you or your covered spouse are
age 65 or over and Then the primary payer is
Original Medicare This Plan
1) Are an active employee with the Federal government (including when
you or
a family member are eligible for Medicare solely because of a
disability),
2) Are an annuitant,
3) Are a reemployed annuitant with the Federal
government when
a) The position is excluded from FEHB, or
b) The position is not excluded from FEHB
(Ask your employing office
which of these applies to you.)
4) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court
judge
who retired under Section 7447 of title 26, U. S. C.
(or if your
covered spouse is this type of judge),
5) Are enrolled in Part B only, regardless of your employment status,
(for Part B (for other
services) services)
6) Are a former Federal employee receiving Workers' Compensation and the
Office of Workers' Compensation Programs has determined that you are (except
for claims
unable to return to duty, related to Workers'
Compensation.)
B. When you or a covered family member have Medicare based on end stage
renal disease (ESRD) and
1) Are within the first 30 months of
eligibility to receive Part A benefits solely
because of ESRD,
2) Have completed the 30-month ESRD coordination period and are still
eligible for Medicare due to ESRD,
3) Become eligible for Medicare due to ESRD after Medicare became primary
for you under another provision,
C. When you or a covered family member have FEHB and
1) Are
eligible for Medicare based on disability, and
a) Are an annuitant, or
b) Are an active employee
c) Are a former spouse of an annuitant, or
d) Are a former spouse of an active employee
Please note, if your Plan physician does not participate in Medicare, you
will have to file a claim with Medicare. 41
41
Page 42 43
2002 Group Health Cooperative of South Central Wisconsin Section 9 42
Claims process when you have the Original Medicare Plan
You
probably will never have to file a claim form when you have
both our Plan
and the Original Medicare Plan.
When we are the primary payer, we process the claim first.
When
Original Medicare is the primary payer, Medicare processes
your claim first.
In most cases, your claims will be coordinated
automatically and we will pay
the balance of covered charges. You
will not need to do anything. To find
out if you need to do
something about filing your claims, call us at 608/
251-4138 x4269.
We do not waive any costs when you have Medicare.
Medicare managed care plan If you are eligible for Medicare, you may
choose to enroll in and get
your benefits from another type of Medicare +
Choice plan a
Medicare managed care plan. These are health care choices
(like
HMOs) in some areas of the country. In most Medicare managed
care
plans, you can only go to doctors, specialists, or hospitals that
are part
of the plan. Medicare managed care plans provide all the
benefits that
Original Medicare covers. Some cover extras, like
prescription drugs. To
learn more about enrolling in a Medicare
managed care plan, contact Medicare at 1-800-MEDICARE
(1-800-
633-4227) or at www. medicare. gov.
If you enroll in a Medicare managed care plan, the following options
are
available to you:
This Plan and another plan's Medicare managed care plan:
You may
enroll in another plan's Medicare managed care plan and
also remain enrolled
in our FEHB plan. We will still provide benefits
when your Medicare managed
care plan is primary, even out of the
managed care plan's network and/ or
service area (if you use our
Plan providers), but we will not waive any of
our copayments
or coinsurance. If you enroll in a Medicare managed care
plan, tell us.
We will need to know whether you are in the Original Medicare
Plan
or in a Medicare managed care plan so we can correctly coordinate
benefits with Medicare.
Suspended FEHB coverage to enroll in a Medicare managed
care plan:
If you are an annuitant or former spouse, you can suspend
your FEHB
coverage to enroll in a Medicare managed care plan,
eliminating your FEHB
premium. (OPM does not contribute to your
Medicare managed care plan
premium.) For information on
suspending your FEHB enrollment, contact your
retirement office.
If you later want to re-enroll in the FEHB Program,
generally you
may do so only at the next open season unless you
involuntarily lose
coverage or move out of the Medicare managed care plan's
service area.
If you do not enroll in If you do not have one or both parts of
Medicare, you can still be
Medicare Part A or Part B covered under
the FEHB Program. We will not require you to enroll
in Medicare Part B, and
if you can't get premium-free Part A, we
will not ask you to enroll in it.
42
42 Page 43 44
2002 Group Health Cooperative of South Central
Wisconsin Section 9 43
TRICARE TRICARE is the health care program
for eligible dependents of military persons and retirees of the military.
TRICARE includes the
CHAMPUS program. If both TRICARE and this Plan cover
you, we
pay first. See your TRICARE Health Benefits Advisor if you have
questions about TRICARE coverage.
Workers' Compensation We do not cover services that:
you need
because of a workplace-related illness or injury that the
Office of Workers'
Compensation Programs (OWCP) or a similar
Federal or State agency determines
they must provide; or
OWCP or a similar agency pays for through a third party injury
settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment,
we will cover your care. You must use our providers.
Medicaid When you have this Plan and Medicaid, we pay first.
When other government agencies We do not cover services and supplies
when a local, state, are responsible for your care or federal government
agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you
for medical or for injuries hospital care for injuries or illness caused
by another person, you
must reimburse us for any expenses we paid. However,
we will
cover the cost of treatment that exceeds the amount you received
in the settlement.
If you do not seek damages you must agree to let us try. This is
called
subrogation. If you need more information, contact us for our
subrogation
procedures. 43
43 Page
44 45
2002 Group Health Cooperative of
South Central Wisconsin Section 10 44
Section 10. Definitions of
terms we use in this brochure
Calendar year January 1 through December
31 of the same year. For new enrollees, the calendar year begins on the
effective date of their enrollment and
ends on December 31 of the same year.
Coinsurance Coinsurance is the percentage of our allowance that you
must pay for your care. See page 11.
Copayment A copayment is a fixed amount of money you pay when you
receive covered services. See page 11.
Covered services Care we
provide benefits for, as described in this brochure.
Custodial care
Custodial care means care that is primarily for the purpose of meeting
personal needs and which could be provided by persons
without professional
skill or training. For example, custodial care
includes help in walking,
getting in or out of bed, bathing, dressing,
eating, preparing special
diets, and taking medicine.
Experimental or We use the following criteria to determine if a
service or procedure investigational services is considered experimental
or investigational:
1. The technology involved must have final approval from the
appropriate
government regulatory bodies;
2. The scientific evidence must allow
conclusions to be drawn based
on health outcomes;
3. The technology
involved must improve the health outcome of
the member;
4. The
technology involved must be as good for a patient as any of
the already
established alternatives; and
5. Possible harm from the procedure (including
long term effects)
must be well understood and not outweigh the benefits.
Contact us if you would like more information about the criteria
used in
deciding whether a service or procedure is experimental
or investigational.
Medically necessary Medically necessary means a service or supply that
is determined by the GHC medical director to be required for the treatment or
evaluation of a medical condition, is consistent with the diagnosis,
and
which could not have been omitted under generally accepted
medical standards
or provided in a less intensive setting.
Plan allowance Plan allowance is the amount we use to determine our
payment and your coinsurance for covered services.
Us/ we Us and we refer to Group Health Cooperative of South Central
Wisconsin.
Yo u You refers to the enrollee and each covered family
member. 44
44 Page
45 46
2002 Group Health Cooperative of South Central Wisconsin Section 11 45
Section 11. FEHB facts
No preexisting condition We will not
refuse to cover the treatment of a condition that you had limitation
before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your
employing or retirement office about enrolling in the can answer your
questions, and give you a Guide to Federal
FEHB Program
Employees Health Benefits Plans, brochures for other plans, and other
materials you need to make an informed decision about:
When you may change your enrollment;
How you can cover your family
members;
What happens when you transfer to another Federal agency, go on
leave without pay, enter military service, or retire;
When your
enrollment ends; and
When the next open season for enrollment begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your
employing or retirement office.
Types of coverage available Self Only coverage is for you alone. Self
and Family coverage is for for you and your family you, your spouse, and
your unmarried dependent children under age
22, including any foster
children or stepchildren your employing or
retirement office authorizes
coverage for. Under certain
circumstances, you may also continue coverage
for a disabled child
22 years of age or older who is incapable of
self-support.
If you have a Self Only enrollment, you may change to a Self and
Family
enrollment if you marry, give birth, or add a child to your
family. You may
change your enrollment 31 days before to 60 days
after that event. The Self
and Family enrollment begins on the first
day of the pay period in which the
child is born or becomes an
eligible family member. When you change to Self
and Family
because you marry, the change is effective on the first day of
the pay
period that begins after your employing office receives your
enrollment form; benefits will not be available to your spouse until
you
marry.
Your employing or retirement office will not notify you when a
family member is no longer eligible to receive health benefits, nor
will
we. Please tell us immediately when you add or remove family
members from
your coverage for any reason, including divorce, or
when your child under
age 22 marries or turns 22.
If you or one of your family members is enrolled in one FEHB plan,
that
person may not be enrolled in or covered as a family member by
another FEHB
plan. 45
45 Page
46 47
2002 Group Health Cooperative of
South Central Wisconsin Section 11 46
When benefits and The
benefits in this brochure are effective on January 1. If you joined premiums
start this Plan during Open Season, your coverage begins on the first day
of your first pay period that starts on or after January 1. Annuitants'
coverage and premiums begin on January 1. If you joined at any
other
time during the year, your employing office will tell you the
effective date
of coverage.
Your medical and claims We will keep your medical and claims
information confidential. records are confidential Only the following
will have access to it:
OPM, this Plan, and subcontractors when they
administer
this contract;
This Plan and appropriate third parties,
such as other insurance
plans and the Office of Workers' Compensation
Programs (OWCP),
when coordinating benefit payments and subrogating claims;
Law enforcement officials when investigating and/ or prosecuting
alleged civil or criminal actions;
OPM and the General Accounting
Office when conducting audits;
Individuals involved in bona fide medical
research or education
that does not disclose your identity; or
OPM,
when reviewing a disputed claim or defending litigation
about a claim.
When you retire When you retire, you can usually stay in the FEHB
Program. Generally, you must have been enrolled in the FEHB Program for the
last five years of your Federal service. If you do not meet this
requirement, you may be eligible for other forms of coverage, such
as
temporary continuation of coverage (TCC).
When you lose benefits When FEHB coverage ends You will receive an
additional 31 days of coverage, for no additional
premium, when:
Your
enrollment ends, unless you cancel your enrollment, or
You are a family
member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary
Continuation
of Coverage.
Spouse equity If you are divorced from a Federal employee or
annuitant, you may
coverage not continue to get benefits under your
former spouse's enrollment.
But, you may be eligible for your own FEHB
coverage under the
spouse equity law. If you are recently divorced or are
anticipating a
divorce, contact your ex-spouse's employing or retirement
office to
get RI 70-5, the Guide to Federal Employees Health Benefits
Plans
for Temporary Continuation of Coverage and Former Spouse
Enrollees, or other information about your coverage choices.
Temporary Continuation If you leave Federal service, or if you lose
coverage because you no
of Coverage (TCC) longer qualify as a family
member, you may be eligible for
Temporary Continuation of Coverage (TCC).
For example, you can
receive TCC if you are not able to continue your FEHB
enrollment
after you retire, if you lose your job, if you are a covered
dependent
child and you turn 22 or marry, etc.
You may not elect TCC if you are fired from your Federal job due to
gross
misconduct. 46
46 Page
47 48
2002 Group Health Cooperative of South Central Wisconsin Section 11 47
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the
RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees,
from your employing or retirement office or
from
www. opm. gov/ insure. It explains what you have to do to enroll.
Converting to You may convert to a non-FEHB individual policy if:
individual coverage Your coverage under TCC or the spouse equity
law ends (if you
canceled your coverage or did not pay your premium, you
cannot convert);
You decided not to receive coverage under TCC or the
spouse
equity law; or
You are not eligible for coverage under TCC or
the spouse
equity law.
If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member
who
is losing coverage, the employing or retirement office will not
notify you. You must apply in writing to us within 31 days after you
are no longer eligible for coverage.
Your benefits and rates will differ from those under the FEHB
Program;
however, you will not have to answer questions about your
health, and we
will not impose a waiting period or limit your
coverage due to pre-existing
conditions.
Getting a Certificate of The Health Insurance Portability and
Accountability Act of 1996 Group Health Plan Coverage (HIPAA) is a
federal law that offers limited federal protections for
health coverage
availability and continuity to people who lose
employer group coverage. If
you leave the FEHB Program, we will
give you a Certificate of Group Health
Plan Coverage that indicates
how long you have been enrolled with us. You
can use this certificate
when getting health insurance or other health care
coverage. Your
new plan must reduce or eliminate waiting periods,
limitations, or
exclusions for health related conditions based on the
information in
the certificate, as long as you enroll within 63 days of
losing
coverage under this Plan. If you have been enrolled with us for less
than 12 months, but were previously enrolled in other FEHB plans,
you
may also request a certificate from those plans.
For more information, get OPM pamphlet RI 79-27, Temporary
Continuation
of Coverage (TCC) under the FEHB
Program. See also
the FEHB web site (www. opm. gov/ insure/ health);
refer to the "TCC
and HIPAA" frequently asked questions. These highlight
HIPAA
rules, such as the requirement that federal employees must exhaust
any TCC eligibility as one condition for guaranteed access to
individual
health coverage under HIPAA, and have information about
federal and state
agencies you can contact for more information. 47
47
Page 48 49
2002 Group Health Cooperative of South Central Wisconsin Long-Term Care
Insurance 48
Long-Term Care Insurance Is Coming Later in 2002!
Many FEHB enrollees think that their health plan and/ or Medicare will
cover their long-term care needs.
Unfortunately, they are WRONG!
How
are YOU planning to pay for the future custodial or chronic care you need?
You should consider buying long-term care insurance.
The Office of Personnel Management (OPM) will sponsor a high-quality
long-term care insurance program effective
October 2002. As part of its
educational effort, OPM asks you to consider these questions:
What is long-term care It's insurance to help pay for long-term care
services you may need if you can't take
(LTC) insurance? care of
yourself because of an extended illness or injury, or an age-related disease
such
as Alzheimer's.
LTC insurance can provide broad, flexible
benefits for nursing home care, care in an
assisted living facility, care in
your home, adult day care, hospice care, and more. LTC
insurance can
supplement care provided by family members, reducing the burden you
place on
them.
I'm healthy. I won't need Welcome to the club!
long-term
care. Or will I? 76% of Americans believe they will never need long-term
care, but the facts are that
about half of them will. And it's not just the
old folks. About 40% of people needing
long-term care are under age 65. They
may need chronic care due to a serious accident,
a stroke, or developing
multiple sclerosis, etc.
We hope you will never need long-term care, but
everyone should have a plan just in
case. Many people now consider
long-term care insurance to be vital to their financial
and retirement
planning.
Is long-term care expensive? Yes, it can be very expensive . A year
in a nursing home can exceed $50,000. Home care
for only three 8-hour shifts
a week can exceed $20,000 a year. And that's before inflation!
Long-term
care can easily exhaust your savings. Long-term care insurance can protect
your savings.
But won't my FEHB plan, Not FEHB. Look at the "Not covered"
blocks in sections 5( a) and 5( c) of your FEHB
Medicare or Medicaid
cover brochure. Health plans don't cover custodial care or a stay in an
assisted living facility
my long-term care? or a continuing need for
a home health aide to help you get in and out of bed with other
activities
of daily living. Limited stays in skilled nursing facilities can be covered in
some circumstances.
Medicare only covers skilled nursing home care
(the highest level of nursing care) after
a hospitalization for those who
are blind, age 65 or older or fully disabled. It also has a
100 day limit.
Medicaid covers long-term care for those who meet their state's poverty
guidelines, but
has restrictions on covered services and where they can be
received. Long-term care
insurance can provide choices of care and
preserve your independence.
When will I get more Employees will get more information from their
agencies during the LTC open
information on how to enrollment period
in the late summer/ early fall of 2002.
apply for this new Retirees
will receive information at home.
insurance coverage?
How can I find out more Our toll-free teleservice center will begin
in mid-2002. In the meantime, you
can learn
about the program NOW? more about the program on our web
site at www. opm. gov/ insure/ ltc. 48
48 Page 49 50
2002 Group Health Cooperative of South Central Wisconsin Index 49
Index
Do not rely on this page; it is for your convenience
and may not show all pages where the terms appear.
Accidental injury 34
Allergy care 17
Allogenic (donor) bone marrow
transplant 24
Alternative treatment 21
Ambulance 26, 28
Anesthesia 24
Autologous bone marrow
transplant 24
Biopsies 22
Blood and blood plasma 25
Bone marrow transplants 24
Breast cancer screening 15
Casts 25
Catastrophic protection 12
Changes for 2002 8
Chemotherapy 17
Childbirth 16
Chiropractic
21
Cholesterol tests 15
Claims 36
Coinsurance 12, 44
Colorectal cancer screening 15
Congenital anomalies 22, 23
Contraceptive devices
and drugs 16
Coordination of benefits 39
Copayment
12, 44
Covered services 44
Covered providers 6, 9
Crutches 20
Deductible 12, 44
Definitions 44
Dental care 34
Diagnostic services 14
Dialysis 17
Disputed claims review 37
Donor expenses (transplants) 24
Dressings 25
Durable medical equipment
(DME) 20
Educational classes
and programs 21
Effective date of enrollment 46
Emergency 27
Experimental or
investigational 44
Eyeglasses 19
Family planning 16
Fecal occult
blood test 15
Foot care 19
Fraud 5
General Exclusions 35
Genetic Counseling 16
Hearing services
16, 18, 33
HIPAA 47
Home
health services 20
Hospice care 26
Home nursing care 20
Hospital 10
Identification cards 9
Immunizations 15, 16
Infertility 17
In hospital physician care 14
Inpatient Hospital Benefits 25
Insulin
20, 32
Laboratory and pathological
services 15
Machine diagnostic tests 15
Magnetic Resonance Imagings
(MRIs) 15
Mammograms 15
Maternity Benefits 16
Medicaid 43
Medicare 39
Mental Conditions/
Substance Abuse Benefits 29
Newborn care 14
Nurse
Licensed Practical Nurse 20
Nurse
Anesthetist 25
Nurse Practitioner 9
Registered Nurse 20
Nursery charges 16
Obstetrical care 16
Occupational therapy 18
Office visits
14
Oral and maxillofacial surgery 23
Orthopedic devices 19
Orthotics 19
Ostomy and catheter supplies 20
Out-of-pocket expenses 12
Outpatient
facility care 26
Oxygen 20
Pap test 15
Physical examination 15, 16
Physical therapy 18
Physician 6, 9
Preadmission testing 25
Preventive care, adult 15
Preventive care, children 16
Prescription drugs 31
Preventive services 15, 16
Prior approval 11
Prostate cancer
screening 15
Prosthetic devices 19
Psychiatrist 29
Psychologist 29
Radiation therapy 17
Rights 6
Room and board 25
Second
surgical opinion 14
Service area 7
Skilled nursing facility care 14, 26
Smoking cessation 21, 32
Speech therapy
18
Splints 25
Spouse equity
46
Sterilization procedures 16, 22
Subrogation 43
Substance abuse 29
Surgery 22
Anesthesia 24
Oral 23
Outpatient 26
Reconstructive 23
Syringes
32
Temporary continuation
of coverage 46
TMJ treatment 23
Transplants
24
Treatment therapies 17
TRICARE 43
Urgent Care 14
Vision services 16, 18
Well child care
16
Wheelchairs 20
Workers'
compensation 43
X-rays 15 49
49 Page 50 51
2002 Group Health Cooperative of South Central
Wisconsin Notes 50
Notes 50
50
Page 51 52
2002
Group Health Cooperative of South Central Wisconsin Benefit Summary 51
Summary of benefits for Group Health Cooperative -2002
Do not
rely on this chart alone. All benefits are provided in full unless indicated
and are subject to the definitions,
limitations, and exclusions in this
brochure. On this page we summarize specific expenses we cover; for more
detail, look inside.
If you want to enroll or change your enrollment in this Plan, be sure to
put the correct enrollment code from the cover
on your enrollment form.
We only cover services provided or arranged by Plan physicians, except in
emergencies.
Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office Office visit
copay: $10 primary care; 14
$10 specialist
Services provided by a hospital:
Inpatient Nothing 28
Outpatient Nothing 28
Emergency benefits:
In-area $25 per visit 27
Out-of-area $25 per visit 27
Mental health and substance abuse treatment Regular cost sharing 29
Prescription drugs $6 copay for generic drugs; $12 copay 31
for name
brand drugs
Up to a 34 day supply per prescription unit or refill
Dental Care Preventive dental care Nothing if by a Participating dentist; 34
50% if by a non-Participating dentist
Accidental injury benefit Nothing
Vision Care One refraction annually Nothing 18
Special features:
Services for deaf and hearing impaired; and Centers of excellence 33
for
transplants/ heart surgery, etc.
Protection against catastrophic costs We do not have an out-of-pocket 12
(your out-of-pocket maximum) maximum 51
51
Page 52
2002 Group Health Cooperative
of South Central Wisconsin Premium Page 52
2002 Rate Information for
Group Health Cooperative of South Central Wisconsin
Non-Postal rates apply to non-Postal enrollees. If you are in a
special enrollment category, refer to the FEHB Guide for
that category or
contact the agency that maintains your health benefits enrollment.
Postal rates apply to career Postal Service employees. Most employees
should refer to the FEHB Guide for United
States Postal Service Employees,
RI 70-2. Different postal rates apply and special FEHB guides are published for
Postal
Service Nurses, RI 70-2B; and for Postal Service Inspectors and
Office of Inspector General (OIG) employees (see
RI 70-2IN).
Postal rates do not apply to non-career postal employees, postal retirees, or
associate members of any postal
employee organization who are not career
postal employees. Refer to the applicable FEHB Guide.
Non-Postal premium Postal Premium
Biweekly Monthly Biweekly
Type
of Gov't Your Gov't Your USPS Your
Enrollment Code Share Share Share Share
Share Share
Self Only WJ1 $87.13 $29.04 $188.78 $62.92 $103.10 $13.07
Self
and Family WJ2 $223.41 $88.38 $484.06 $191.49 $263.75 $48.04 52